Audit of allergen controls and relevant open audit actions

Foreword

The Food Standards Agency (FSA) is the Competent Authority (CA) responsible for feed and food safety and standards legislation and for ensuring risk-based official controls are carried out at feed and food business establishments in Wales, England, and Northern Ireland.

Feed and food official controls aimed at verifying food business compliance are fundamental to safeguarding public health and contribute to the FSA’s strategic outcome that ‘food is safe and what it says it is’.

Day-to-day monitoring and enforcement of feed and food business compliance is the responsibility of local authorities (LAs).

In Wales, the power to set standards and monitor LA feed and food law enforcement services was conferred on the FSA under Section 12 of the Food Standards Act 1999 and Regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009.  The FSA is required to monitor and audit local authority feed and food law enforcement services under this legislation and the assimilated Official Controls Regulation (EU) 2017/625. In developing its audit arrangements, the FSA has taken account of the European Commission guidance on how such audits should be conducted.

In addition to assessing the delivery of official controls against legal requirements and statutory guidance, the audit process also provides the opportunity to identify and disseminate good practice and to provide information to inform FSA policy on the execution and enforcement of feed and food law.

FSA audit programmes assess local authorities’ conformance against the requirements of the assimilated Official Controls Regulation (EU) 2017/625 and the Feed and Food Law Enforcement Standard within the Framework Agreement on Official Feed and Food Controls by Local Authorities (Framework Agreement). Assessments were also made against the Food Law Code of Practice (Wales) 2021 (FLCoP) along with related centrally issued guidance including the Food Law Practice Guidance (Wales) 2021 (FLPG). A new Code of Practice and Practice Guidance has been published and will be applied ongoing recommendations where applicable.

 

This report is available in hard copy from the FSA’s Regulatory Audit and Assurance Team, Asiantaeth Safonau Bwyd yng Nghymru / Food Standards Agency in Wales, Llawr 4 / 4th Floor, Adeilad Llywodraeth Cymru / Welsh Government Building, Parc Cathays Park, Caerdydd / Cardiff, CF10 3NQ, and electronically on the FSA’s website.

Table of Contents

1.0 Introduction
Background
Scope of Audit Plan

2.0 Executive Summary

3.0 Audit Methodology

4.0 Audit Findings
Organisation and Management
Authorised Officers
Food Premises Inspections, Records & Reports
Food Inspection and Sampling
Food and Food Premises Complaints
Enforcement 
Internal Monitoring
Relevant Open Audit Actions

Annex A - Audit plan

Annex B - Allergen controls action plan

1.0 Introduction

Background

1.1 Audits of LA feed and food law enforcement services are part of the FSA arrangements to improve consumer protection and confidence in relation to feed and food. Implementing official controls in food businesses at appropriate frequencies based on risk is essential to protect public health and ensure the safety of food for consumers.

1.2 Following the Covid pandemic, from 1 April 2023, LAs should be planning to:

• Carry out due interventions for establishments that are back in the routine programme of interventions in accordance with the frequencies set out in the FLCoP.
• Work towards realigning with the provisions set out in the FLCoP from 1 April 2023, using the full range of flexibilities already offered by the FLCoP. These flexibilities including exemptions can be found in Chapter 4 of the FLCoP and Chapter 4 of the FLPG.
• Continue to exercise a risk-based approach to the requirements set out in the FLCoP based on available resource.

1.3 A key part of the FSA’s remit in its role as a CA is to provide assurance for stakeholders and the public that food authorities, such as LAs, are correctly delivering and implementing any legislation, advice and guidance issued in relation to the services they provide. This audit programme, in tandem with the bi-annual performance surveys, provides a key element of the FSA’s overall assurance framework. 

1.4 In Wales, the power to set standards and monitor LA feed and food law enforcement services was conferred on the FSA under section 12 of the Food Standards Act 1999 and regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009. 
 
1.5 The Framework Agreement on Local Authority Food Law Enforcement sets out the arrangements through which the FSA monitors and audits LA enforcement activities to help ensure that LAs are providing an effective service to protect public health.

Scope of Audit Plan

1.6 This programme consists of a series of audits across Wales to assess compliance with legislation relating to the provision of allergen information to consumers and the risk posed to hypersensitive consumers, as well as reviewing any relevant open audit actions following previous audits. The audits assess whether LAs are undertaking interventions involving allergen assessments based on a programme of interventions that is in accordance with the FLCoP.  

1.7 The audit assessment considered:

• Food standards service planning, delivery and review,
• Resources available to the service and the risk-based prioritisation of activities, including the assessment of new food businesses.
• Authorisation and competence of officers
• Interventions (programmed and reactive) and Enforcement
• Sampling Policy, procedures and programme
• Internal monitoring
• Any other matters relating to allergen controls
• Open audit actions – review of any relevant open actions from previous audits and associated update of the LA audit action plan.  

1.10 As part of the development of the audit programme the FSA engaged with relevant stakeholders and produced an audit plan.  This is attached in Annex A.

2.0 Executive Summary

2.1 The audit examined Wrexham County Borough Council’s arrangements for the delivery of allergen related official food controls, a major part of the authority’s food standards function. This included a reality check at a food establishment to assess the effectiveness of official controls and more specifically, the checks carried out by the authority’s officers, to verify food business operator (FBO) compliance with legislative requirements.  The scope of the audit also included an assessment of the authority’s overall organisation and management, and the internal monitoring of food standards activities. 

2.2 The Chief Officer Economy & Planning had overall responsibility for the delivery of food standards services within the Public Protection Department.  Day to day management was the responsibility of the Food and Farming Lead and Specialist Public Protection Officer (Food Standards & Feed).
    
2.3 The authority had service planning arrangements in place together with systems for reviewing performance. Service planning documents contained most, but not all of the information set out in the Service Planning Guidance, including the requirement to review all elements of the previous year’s work and address all delivery shortfalls in the next plan. 

2.4 Arrangements were in place to ensure effective service delivery by appropriately authorised, competent officers who had been authorised in accordance with their qualifications, training and experience. Good practice was identified in relation to the allergen training provided to officers. There was, however, a shortage of 1.1 full time equivalent officers required to deliver the authority’s interventions numbers with current practices. However, the challenge of tackling persistently non-compliant businesses requires further additional resources to ensure the authority’s full obligations in relation to allergen controls are being met. Whilst there was an intention to try and address these issues, there was no firm plan in place to fully address the shortage in officer resources, preventing the authority from meeting its obligations.

2.5 Database checks confirmed that whilst high risk interventions were being undertaken, some medium and low risk establishments were overdue a food standards intervention. A large proportion of the overdue medium and low risk premises were likely to carry allergen risks and many of the low-risk premises belong in a higher risk band. Whilst there was an intention to try and catch up on overdue interventions, there was no firm plan in place to fully re-align its intervention frequencies with the FLCoP, preventing the authority from meeting its obligations.

2.6 Intervention records showed that assessments of business allergen control compliance during food standards interventions whilst sometimes of good quality, were occasionally of poor quality. Insufficient information was available in some cases to demonstrate that a thorough assessment had been undertaken by officers. Some good practice was evident in relation to information provided to businesses. Risk rating was variable with some evidence of the need to more accurately reflect allergen risks. Follow up action was generally not being carried out effectively to remove unsafe food from the market or notify the FSA or other authorities.  

2.7 Food standards intervention reports were variable, with some being comprehensive, however, the authority would benefit from ensuring this was consistently the case.  

2.8 Whilst food and food establishment complaints and food standards sampling had generally been undertaken as required, with some good practice, there were examples where the appropriate follow up action was not always undertaken to address the outcomes.   

2.9 The authority had only used informal enforcement tools to try and secure improved business compliance with allergen control legislation. Where enforcement action had been taken it was, generally, appropriate up to a point, however, where repeat contraventions or a failure to fully achieve compliance were identified, a graduated escalation of enforcement to more formal activities was not taking place and non-compliance was not being rectified.  

2.10 There was evidence of some internal monitoring of food standards matters, including allergen controls. The amount of qualitative internal monitoring activity would benefit from being expanded to include more frequent activity, larger sample sizes and more database checks.

3.0 Audit Methodology

3.1 The LA received a pre-audit letter including a pre-visit questionnaire along with details of documents required to assess completion of previously outstanding recommendations.  

3.2 The LA was also provided with a copy of any relevant audit reports /action plans and asked to provide evidence of their progress on outstanding actions. 

3.3 This was followed by a structured on-site audit involving a reality visit to a local business and meetings with the Head of Service, LA lead officer and other relevant staff about current and future service delivery arrangements as well as an examination of a selection of food official controls records.

3.4 The audit took place from the 4th - 6th November 2025. The on-site element of the audit took 2½ working days. 

3.5 The LA received this written audit report and an updated audit action plan, which will be published on the FSA website.

4.0 Audit Findings

4.1 Organisation and Management

4.1.1 Food law enforcement was overseen by the Lead Member Planning & Public Protection. The authority’s Constitution set out its decision-making arrangements. Under the Constitution, decisions on food-related operational matters had been delegated to the Chief Officer Economy & Planning.  

4.1.2 A ‘Food Service plan’ for 2025/2026 (‘the Service Plan’) had been developed by the authority. The Service Plan had been approved by the Lead Member and the Chief Officer.  

4.1.3 The Service Plan contained most of the information set out in the Service Planning Guidance, including a profile of the authority, the scope of the service and organisational structure chart for the Public Protection department. The times of operation, service delivery points and aims and objectives of the service were clearly set out. 

4.1.4 The service plan indicated that there were approximately 1297 food establishments in Wrexham.   The profile of businesses was provided by establishment type.  The number of planned interventions due, by risk rating, had also been provided including those that were overdue.

4.1.5 The targets and priorities for food standards included a commitment to deliver all inspections / interventions due at high-risk establishments as required by the FLCoP but delivery of medium and low risk establishments was being undertaken in accordance with the food hygiene risk rather than the food standards risk, which was commonly due sooner.

4.1.6 The expected number of revisits during the year, forms a required part of the intervention programme. There was a commitment to revisit establishments for food standards in accordance with the requirements of the FLCoP.  

4.1.7 The authority’s priorities and intervention-targets as set out in the Service Plan, were based primarily on food hygiene risk. In some cases, where the food standards risk was high, auditors were informed that food standards risk would be prioritised.  

4.1.8 The plan included an estimate of the likely demand for the food interventions programme, including the likely demand, based on previous years, for the reactive work required to be undertaken.  

4.1.9 Information was provided on the food standards sampling programme and included the resources allocated to undertake this work.  

4.1.10 The resources available to deliver food law enforcement services were detailed in the Service Plan as 7.8 full time equivalent (FTE) officers for both food hygiene and food standards. A figure of 8.9 FTE was estimated as being required to deliver the service, indicating the need for a small amount of additional resources (1.1 FTE) to fully deliver against requirements.

4.1.11 The Service Plan included general information on the authority’s Enforcement Policy and its approach to staff development.  

4.1.12 Arrangements for internal monitoring or ‘quality assessment’ of the food standards service through quantitative reporting arrangements was referenced within the plan. However, the plan would also benefit from the inclusion of a brief description of the qualitative internal monitoring arrangements for the food standards service.

4.1.13 The Service Plan contained information following a review of delivering food official controls against the previous year’s plan.  However, it was noted that whilst the review covered most areas of work, it did not cover all targets. The review should include the number of samples taken against the food standards sampling programme.

4.1.14 Following the review, any variations in achieving the targets set out in the previous Service Plan had not been identified.  Variances for the medium (category B) and low-risk food standards (category C) interventions and unrated businesses had not been identified or explained as required by the service planning guidance.  

4.1.15 The authority had incorporated a number of areas for improvement in its Service Plan, including delivery of food controls in line with the FLCoP; particularly aiming to meet requirements around inspections of existing and newly registered premises with 28 days of the relevant date. Such improvements would allow the authority to address the existing variances.

Recommendations

4.1.16 The authority should:

• (i) Ensure the annual performance review includes all information on the previous year’s performance against the food service plan and any specified performance targets, standards and outcomes. 
• (ii) Ensure all variances in meeting the food service plan is addressed in its subsequent plan.
  [Articles 5(1)(a) & (e) of assimilated Regulation (EU) 2017/625; FLCoP 2.3.3, FLPG 2.3.18.2, 2.3.18.3 & Annex 1]

4.2 Authorised Officers

4.2.1 The authority’s Scheme of Delegation of Powers to Officers, contained within its written Constitution, provided the Chief Officer Planning and Regulatory with delegated powers to execute all duties relating to food services.  This includes the delegated authority to authorise other officers and the power to instigate prosecutions.  The functions of this Chief Officer have been absorbed by the Chief Officer Economy and Planning and the Constitution would benefit from an update accordingly.

4.2.2 A documented procedure had been developed for the authorisation of food standards officers based on their qualifications and experience.  The procedure was comprehensive and accurate and included provision for assessments of competence to be undertaken prior to authorisation.  

4.2.3 The authority had appointed a suitably qualified and competent lead officer for food standards in accordance with the requirements of the FLCoP.  

4.2.4 The authority had identified, within its Service Plan, that the level of resources required to deliver food services was higher than those available, a deficit of 1.1 FTE officers. The authority was not yet able to deliver its obligations of conducting its intervention programmes, undertaking revisits, carrying out a full programme of food sampling and taking the necessary enforcement action with the available resources. The authority was carrying a manageable backlog of food standards interventions but did not have a formal plan to re-align with the FLCoP, although, they had identified opportunities to recoup 0.5 FTE from future staffing changes. However, this additional 0.5 FTE is to be allocated to address the need for additional enforcement work to target the sale of unsafe food from non-compliant premises, meaning that the true shortfall in resources is likely to remain at 1.1 FTE unless additional support is secured. Whilst auditors were advised that the Food & Farming Team are working with partner organisations to identify additional funding that can be used to generate an additional 1 FTE post, this was not guaranteed to happen.  The authority should increase its food service resources to ensure there are sufficient resources available going forward to fully deliver its obligations in law and under the FLCoP. 

4.2.5 Provision of officer training was dependent on a formal training needs assessment. The authority was providing a combination of in-house and externally provided training and making good use of the opportunities afforded by the FSA’s local authority training opportunities. All officers were required to achieve 10 hours of continual professional development (CPD) on core food matters in accordance with the FLCoP. The authority was able to fund training where a need had been demonstrated.

Best practice

The authority had developed and delivered a bespoke allergen training course, in conjunction with a training provider, that provided its officers with practical knowledge and skills on allergen controls.  The training activity was shared with officers from nearby authorities. 

4.2.6 An examination of the qualification and training records of five officers involved in the delivery of official food standards controls was undertaken. Records were being maintained by the authority for officers in the Council’s computer file & folder system.    

4.2.7 All officers had been authorised in accordance with evidence of their qualifications, training and experience. Authorisations had been signed by an officer with the delegated authority and included all the key legislation required for the delivery of the range of official controls required for allergens.  

4.2.8 Academic and other relevant qualifications were available for all officers, and all had received the minimum 10 hours of CPD on core food matters required by the FLCoP and the authority’s own policies, in keeping with their duties. Further, all officers had received the necessary training to deliver the technical aspects of the work for which they are involved.

Recommendations

4.2.9 The authority should:

• (i) Ensure it has a sufficient number of suitably qualified and experienced staff so that official controls and other official activities can be performed efficiently and effectively.
  [Articles 5(1)(e) of assimilated Regulation (EU) 2017/625; FLCoP 3.2]

4.3 Food Premises Inspections, Records and Reports

4.3.1 The authority provided data prior to the audit which confirmed there were 1265 rated food businesses on the authority’s food standards establishment database. There were a total of 49 food establishments overdue a food standards intervention, of which, none were high risk, 22 were medium-risk and 27 were low-risk. Whilst the intervention programme was driven by the food hygiene risk, interventions were being undertaken in premises rated as a high food standards risk, as required. Analysis of the medium and low risk establishments indicated that a large proportion of the medium (82%) and low risk premises (74%) were likely to carry allergen risks and evidence from file checks and premises type data indicated that many of the low-risk premises were likely to belong in a higher risk band. The authority plans to address this backlog of overdue interventions, but this depends on securing additional funding which is not yet guaranteed. Combined with the need to undertake a significant amount of additional enforcement to address non-compliant businesses, as identified below, the likelihood of this being achieved is currently uncertain.  

4.3.2 Food interventions procedures had been developed which were in accordance with requirements.  Food standards interventions were being undertaken in a variety of ways, including separate stand-alone food standards interventions and combined interventions alongside food hygiene interventions. Separate food standards and joint inspection aide-memoire forms were available. The aide memoire required review to ensure full capture of allergen control information and a new proposed proforma was discussed during the audit.

4.3.3 Five food standards interventions carried out in the two years prior to the audit were examined. It was noted that all files contained relevant food registration details, details on the nature & extent of food activities including size, scale and type of food activity and had ratings documented. All observations were legible. Visits had been undertaken at the correct frequency in all but one case, which was not visited until 55 days after registration.

4.3.4 Auditors were able to establish that the appropriate inspection form / aide memoire were used in all interventions, however, the original written records were not present on the files provided at the time of the audit. It was evident from reviewing the file that information had been documented elsewhere but no contemporaneous notes were provided. Four out of five cases documented that an unannounced inspection had taken place whilst one file did not indicate either way. 

4.3.5 Auditors were able to establish that assessments of any food standards management system and discussions had with staff were recorded in four out of five cases. In one case there was insufficient detail to establish whether allergen management had been discussed or reviewed.  

4.3.6 Auditors were able to establish that assessment of incoming traceability requirements in relation to allergens including details of suppliers, other businesses that produce or import for the business and ingredient specifications, were available on all files. 

4.3.7 Compliance with composition, presentation and allergen labelling requirements had been thoroughly assessed in four out of five cases. Insufficient information was available on the remaining file to be able to determine what assessment had been undertaken.

Best practice

Auditors noted that the authority had made use of an allergen information guide for businesses as developed in Lancashire and adapted by a North Wales working group. The information was clear and concise and described business’ legal obligations in lay terms and gave templates to be used for allergen matrices and recipe cards.

4.3.8 In three cases where there had been previous contraventions details were available to demonstrate that these had been reviewed. However, in all these cases there were still outstanding contraventions. In one case the premises had been revised from an A rated premises to a B but no reason for this decision was documented on the premises file. Auditors were able to determine that there were still significant breaches remaining relating to inaccurate Allergen labelling. Having regard to this evidence auditors determined that the rating should have remained an A to ensure the higher frequency of inspections due to a history of non-compliance with allergen labelling. Auditors were able to determine that the ratings in the remaining four cases were appropriate.

4.3.9 Auditors were able to determine that the assessment as to whether to take samples was only documented in two cases.

4.3.10 In four out of five cases auditors were able to determine that appropriate follow-up action had not been taken in light of inspection findings and that recurrent contraventions remained. Revisits were undertaken but timelines for compliance were repeatedly extended. Considerations as to the removal of unsafe food from sale were not adequately explored or recorded. There was no evidence that a graduated enforcement approach had been taken, as required by the authority’s enforcement procedure and the FLCoP.  

4.3.11 Auditors were able to determine that in three of these cases, where food hazards were identified, incidents should have been raised with the FSA as there were serious localised hazards or implications outside of the authority. No other LAs had been informed in accordance with Primary Authority / Home Authority schemes.

4.3.12 All reports of visits had been sent in an appropriate timeframe. All reports had been addressed to the correct trading name and address of the business and three inspection reports contained all the required information.

4.3.13 The remaining two files lacked numerous requirements of the Code with one case not referencing the Food Standards visit. The following information was not available in these two cases:

• Description of purpose of OCs
• Control methods applied
• Address of the business, and registered address if different
• Person seen/interviewed
• Date and time of inspection
• Specific food law under which inspection conducted
• Areas inspected
• Documents/other records examined
• Samples taken
• Key points discussed during the inspection including outcome of OCs & any non-compliances identified.
• Actions to be taken by the food authority

4.3.14 Whilst copies of food business records, including registration forms, inspection aide-memoires, post inspection visit report forms and correspondence were provided, the original electronic records were not retrievable.  

4.3.15 In three out of five cases, intervention dates documented on the copied records provided did not align with the dates documented on the inspection reports. 

4.3.16 The authority reported that it was not currently using an alternative enforcement strategy for lower risk establishments, however there was a procedure covering this activity.

Recommendations

4.3.17 The authority should:

• (i) Ensure that food standards interventions/inspections are carried out at the minimum frequency specified by the FLCoP. [Articles 9(1) & (2) of assimilated Regulation (EU) 2017/625; FLCoP 4.2, 4.2.2, 4.2.4 & 4.2.5]
• (ii) Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection includes complete information for assessments of food standards management systems, labelling, presentation and whether to take samples.  [Articles 5(1)(a) & (b), 9(1), 12, 13 & 14 of assimilated Regulation (EU) 2017/625; FLCoP 4.4, 4.6, 4.3.3.1; FLPG 4.3.4.2, 4.3.4.3, 4.6]
• (iii) Ensure premises are rated correctly in relation to allergen matters and that justification for any revision is recorded.  [Articles 5(1)(a) & (b), 9(1), 12, 13 & 14 of assimilated Regulation (EU) 2017/625; FLCoP 4.2.2, 4.2.6, Annex 1]
• (iv) Ensure that the establishment database & any information management system is capable of retrieving all food establishment information and providing the information requested by the FSA. Ensure that intervention report letters contain all of the required information.  [Articles 5(1)(f) & 13 of assimilated Regulation (EU) 2017/625; FLCoP 2.6, 2.6.3, 4.6; FLPG 4.6]

Verification Visit to Food Establishment

4.3.18 A verification visit was undertaken at a food establishment with the authorised officer of the authority who had carried out the most recent food standards inspection. The main objective of the visit was to consider the effectiveness of the authority’s assessment of the systems within the business for ensuring that food meets the requirements of food standards law in relation to allergen controls.

4.3.19 The officer was able to demonstrate their knowledge of the business and provide auditors with an assurance that assessments of allergen controls had taken place as part of the inspection.  However, the visit also confirmed the importance of fully recording detailed inspection observations on the appropriate aide memoire and the importance of capturing the nature and extent of the different products being offered for sale.  It further confirmed the need to implement appropriate follow up action, including that of ensuring unsafe food is dealt with appropriately. Food that was unsafe due to incorrect allergen labelling remained on sale following the visit. It also highlighted the need to ensure that Primary and Home Authorities along with the FSA Incidents team are suitably informed when there is unsafe food being placed on the market in Wrexham.

4.4 Food Inspection and Sampling

4.4.1 The authority’s Service Plan contained information on food standards sampling indicating participation in projects or surveys, routine inspection-based sampling based on risk and sampling in response to matters arising. Auditors were provided with a sampling plan for this current financial year, that considered food standards sampling, including that for allergens.

4.4.2 The authority had appointed a Public Analyst for carrying out analyses of food. The laboratory was on the recognised list of UK designated Official Laboratories. 

4.4.3 The procedure outlined how to take samples as well as steps to take following receipt of results. 

4.4.4 Five food standards samples carried out in the two years prior to the audit were examined. All samples had been taken by appropriately trained and authorised officers and sample results were available on file. Auditors were able to confirm that, all food business operators had been informed of the results and where appropriate, the Primary Authority had also been notified.

Best practice

The authority issued a Police and Criminal Evidence Act notice to all cases examined at the time of taking the sample. The notice was a duplicate form demonstrating that business owners were fully informed of the powers of officers, the samples taken and their purpose.

4.4.5 In three cases auditors were able to confirm that appropriate action had been undertaken in relation to the sample result. In one case, where a sample visit revealed non-compliances, the rating issued following a subsequent inspection did not reflect the recent compliance track record. Another case would have benefitted from further investigation/ action to address the non-compliance identified.

Recommendations

4.4.6 The authority should:

• (i) Ensure that appropriate action is taken in relation to non-compliance following sampling. [Articles 5, 12, 137 & 138 of assimilated Regulation (EU) 2017/625; FLCoP 2.5, 4.3, 5.2, 6.3, 6.4; FLPG 6.3, 6.4]

4.5 Food and Food Premises Complaints

4.5.1 The authority has developed a procedure for undertaking food related complaints which outlined the criteria for investigations.

4.5.2 An examination of records relating to five complaints or service requests received by the authority were undertaken. Auditors were able to confirm that complaints had been investigated within a timely manner.

4.5.3 In four cases auditors were able to determine that the cases had been appropriately investigated with the one remaining case it would have benefitted from further investigatory action.

4.5.4 Where appropriate, all complainants had been notified of the results of the   investigation and appropriate action had been taken in four of the cases.

Recommendations

4.5.5 The authority should:

• (i) Ensure that food complaints or service requests are thoroughly investigated and appropriate action taken in relation to non-compliance. [Articles 5, 12, 137 & 138 of assimilated Regulation (EU) 2017/625; 6.3 FLCoP & 6.3.3 FLPG]

4.6 Enforcement

4.6.1 The authority had developed a Public Protection Service Enforcement Policy. The policy had received the appropriate approval and was available to the public and businesses upon request. The Policy was supplemented by the Food Safety Enforcement Procedure, however, the procedure had not been approved.  

4.6.2 These documents advocated a graduated approach to enforcement and taken together, were generally in accordance with the FLCoP and other official guidance. The Policy provided criteria for issuing simple cautions and taking prosecutions and made reference to the Primary Authority scheme. However, it did not contain criteria for the taking of informal action, the service of various statutory notices and other formal actions as required by the FLCoP. Whilst such criteria were present in the procedure, this had not received the necessary approval.

4.6.3 The taking of action in establishments where the Council itself has an interest such as schools, leisure centres and care homes, was addressed in the policy.  

4.6.4 The Food Safety Enforcement Procedure provided overarching expectations with regards to certain enforcement actions; including Food Information Regulation Improvement Notices (FIRINs), Remedial Action Notices (RANs), Voluntary Closure, Prohibition Notices and Orders, seizure, detention, certification and voluntary surrenders, simple cautions & prosecutions. 

4.6.5 Specific procedures relating to Improvement Notices, Voluntary Closure, Remedial Action Notices, Prohibition Notices and Orders, seizure, detention, certification and voluntary surrenders lacked detail including links to template notices on prescribed forms and where these documents are saved. The procedures also required detailed information on service of notices, not just delivery by hand, proof of service and retention of true copies. Also, any associated documents for compliance and withdrawal should be referenced. No cases relating to the above enforcement actions had been undertaken within the timeframe of the audit.

4.6.6 Whilst the authority had procedures for the commencement of prosecutions and undertaking simple cautions, those procedures had not yet been fully documented.  The procedures require further development to document information on how officers access template documents for compiling a case file and local arrangements for the progression of a case, having regard to Criminal Procedures Investigation Act 1996 roles and responsibilities.  No cases relating to these actions had been undertaken within the scope of this audit.

Recommendations

4.6.7 The authority should:

• (i) Review and amend its enforcement policy to include criteria for the taking of informal action, the service of various statutory notices and other formal actions as required by the FLCoP.  [Articles 5(1(a),(b), 137 & 138 of assimilated Regulation (EU) 2017/625, FLCoP 2.3, 2.3.2 & FLPG 2.3.14] 
• (ii) Review and amend its enforcement procedures to include local arrangements for drafting and maintaining proof of service for statutory notices along with the process of compiling and approving files for decisions on prosecution / simple cautions.  [Articles 5(1 (a) & (b), 12, 13, 137 & 138 of assimilated Regulation (EU) 2017/625, FLCoP 2.3, 2.3.1 & FLPG 2.3.10] 
• (iii) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied. This should include the provision of information to FSA Incidents Team and other local authorities. [Article 138 of assimilated Regulation (EU) 2017/625; FLCoP 2.5, 5.2, 6.3 & 6.4, FLPG 2.8, 6.3.3]

4.7 Internal Monitoring

4.7.1 Internal monitoring is important to ensure performance targets are met, services are being delivered in accordance with legislative requirements, centrally issued guidance and the authority’s procedures. It also ensures consistency in service delivery. 
  
4.7.2 Key performance targets have been identified in line with the FLCoP and the authority has arrangements in place for both quarterly and annual quantitative internal monitoring across the food services. Performance was reported through the corporate performance monitoring system. Further monitoring of the progress of intervention programmes is monitored regularly by the lead officer. 
 
4.7.3 A documented internal monitoring procedure had been developed for the food services including accompanied visits and a sample of file checks across most official control activities. The procedure would benefit from improvement to specify an increased sample size / frequency of internal monitoring activity and a wider range of bulk database checks.  

4.7.4 The Food and Farming lead and Specialist Officers were responsible for internal monitoring of the food enforcement services at an operational level.

4.7.5 Auditors were able to verify that some qualitative internal monitoring had been undertaken across the service including record checks.  

4.7.6 Records maintained, in accordance with the procedure, were able to confirm the nature and extent of the monitoring activity. Auditors were able to verify that the qualitative monitoring that had been undertaken across both services including accompanied inspections, intervention file record checks, and service requests.  

4.7.7 The amount and extent of internal monitoring taking place in practice would benefit from expansion to include more frequent activity, larger sample sizes and a wider range of database checks.

4.7.8 The records relating to internal monitoring that were available, were being maintained by managers for at least two years.

Recommendations

4.7.9 The authority should:

• (i) Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should specify an increased sample size / frequency of internal monitoring activity and a wider range of bulk database checks.
• (ii) The amount and extent of internal monitoring taking place in practice should, similarly, be expanded to include an increased sample size / frequency of internal monitoring activity and a wider range of database checks.
  [OCR Arts 5(1a&b) & 12, FLCoP 2.3.1 & FLPG 2.3.2]

4.8 Relevant open audit actions

4.8.1 Relevant open audit actions from previous audit programmes were followed up.  This includes those from the full audit programme of 2013 - 2017 and the Food Hygiene Rating Scheme focussed audit of 2017.  

4.8.2 An updated action plan has been published on the FSA website.

Auditors

Craig Sewell
Angela Phillips

Division:

Regulatory Audit and Assurance Team, 
Asiantaeth Safonau Bwyd yng Nghymru / Food Standards Agency in Wales, 
Llawr 4 / 4th Floor, 
Adeilad Llywodraeth Cymru / Welsh Government Building, 
Parc Cathays Park, 
Caerdydd / Cardiff, 
CF10 3NQ

Annex A: Audit Plan

 

Food Standards Agency in Wales

 

Local authority audit plan – Wales

April 2025 – March 2026

 

Programme Brief

Sarah Maddox
Head of Regulatory Audit and Assurance, FSA in Wales
Email Sarah.Maddox@food.gov.uk

Craig Sewell
Senior Audit Manager, FSA in Wales  – Lead Auditor
Email wales.audit@food.gov.uk

Background

1. In Wales, the power to set standards and monitor local authority (LA) feed and food law enforcement services was conferred on the Food Standards Agency (FSA) under section 12 of the Food Standards Act 1999 (the Act) and regulation 7 of the Official Feed and Food Controls (Wales) Regulations 2009 (OFFC).

2. The Act provides the FSA with statutory powers to strengthen its influence over enforcement activity and to ensure national priorities and objectives will be delivered at a local level. It gives the FSA powers to carry out the following duties:

• set standards of performance in relation to enforcement of feed and food law
• monitor the performance of feed and food law enforcement authorities
• require information from LAs relating to food law enforcement and to inspect any records
• enter LA premises, to inspect records and take samples
• publish information on the performance of LAs
• make reports to individual LAs, including guidance on improving performance

3. Assimilated Regulation (EU) 2017/625 on official controls and other official activities performed to ensure the verification of compliance with feed or food law includes a requirement, under Article 6, for competent authorities to carry out internal audits or to have external audits carried out. 

4. To fulfil this requirement the FSA provides assurance for stakeholders and the public that competent authorities (CAs) such as LAs, are correctly delivering and implementing any legislation, advice and guidance issued in relation to the services they provide. This audit programme, in tandem with the bi-annual performance surveys, provides a key element of the FSA’s overall assurance framework.

5. The audits in this audit programme will be a systematic and independent examination of the delivery of official controls by LAs in relation to food law in Wales.

Programme Objectives

6. The audit programme will look at official controls and official activities carried out from 01 April 2023. Management activities relating to the implementation of the legislation in the criteria before this date will also be included in the audit programme.

7. The audits will demonstrate whether the implementation of official food controls relating to allergens in Wales has been effective. Failure to secure compliance with food law which could detrimentally affect the health and welfare of people in Wales could result in reputational damage to LAs and the FSA, as well as loss of confidence in the food industry.

8. The focused audit programme will include an examination of the official controls, official activities and related results that are used by LAs to achieve the objectives of the Legislation below:

• The Food Safety Act 1990
• Assimilated Regulation (EU) No 1169/2011 on the provision of Food Information to Consumers 
• The Food Information (Wales) Regulations 2014

9. The specific aims of this audit programme are to:

• provide assurance that the delivery of allergen labelling legislation that has been in operation since 2014 in Wales, has been effectively implemented by LAs; in that official controls are being delivered in accordance with the Food Law Code of Practice (Wales) (the Code), Food Law Practice Guidance (Wales), Framework Agreement and other centrally issued, official guidance and legislation.*  
• evaluate LA activities in relation to food businesses providing products Pre-Packed for Direct Sale (PPDS) to consumers which came into force in October 2021.
• identify and disseminate any areas of good practice and innovation to other LAs to improve the effectiveness and efficiency of controls being delivered  
• provide a means to identify under performance in the LAs food law enforcement systems
• provide information to aid the development of FSA policy.
• review LA progress in implementing any relevant outstanding recommendations from previous audits

* The Code used will be relevant to the timing of the delivery of the relevant controls.

Scope of the Audit Programme

10. This programme will consist of a series of audits across Wales to assess the compliance with legislation relating to the provision of allergen information to consumers and the risk posed to hypersensitive consumers, as well as reviewing any relevant open audit actions following previous audits. The audits will assess whether LAs are undertaking interventions involving allergen assessments based on a programme of interventions that is in accordance with the Code.

11. The audit programme will focus on the risks associated with the following areas of official control:

• Food standards service planning, delivery and review,  
• Resources available to the service and the risk-based prioritisation of activities, including the assessment of new food businesses. 
• Authorisation and competence of officers 
• Interventions (programmed and reactive) and Enforcement
• Sampling Policy, procedures and programme 
• Internal monitoring
• Any other matters relating to allergen controls

12. Open audit actions – review of any relevant open actions from previous audits and associated update of the LA audit action plan.

Assessment Approach

13. The audits will involve:

• a pre-audit questionnaire requesting copies of the LA service plans, planned/completed interventions and associated documentation  
• the LA will also be provided with a copy of previous audit action plans and will be asked to provide evidence of their progress on any outstanding actions 
• this will be followed by a structured on-site audit involving meetings with the Head of Service, LA lead officers and other relevant staff about current and future service delivery arrangements, a reality check visit and case file reviews.

Notification

14. Prior notification of 4 weeks for the submission of pre-audit material and at least 6 weeks of an audit visit, will be given for each audit carried out under this audit plan. This will aid transparency and facilitate the effectiveness of the audit process by allowing plenty of time for each LA to collate documents and ensure appropriate staff and facilities are available.

Timing

15. The audits will take place between May 2025 and February 2026. The on-site element of the audit, for each LA, should take 2 working days for assessment work followed by a closing meeting on a third day.

Assessment Report and Follow Up

16. All LAs in the programme will receive an individual report and an updated audit action plan, both of which will be published on the FSA website.  An assessment of overall assurance for allergen controls will also be sent to each local authority but will not be published.

17. At the end of the programme an anonymised summary report will be produced which will contain findings from the audit programme. The summary report will include recommendations for LAs and the FSA to improve the delivery of official controls. The summary report will also highlight any common themes and emerging issues as well as any areas of good practice identified during the programme.

Planned Outcomes

Immediate Outcomes

• Provide assurance regarding the arrangements in place for the delivery of LA official controls in managing the food safety risk relating to hypersensitive individuals posed by exposure to Allergens  
• Improvements and actions taken by LAs contribute to more effective local food law enforcement 
• Wider dissemination of identified good practice will contribute to improvements in quality and effectiveness of LA delivery of official food controls 
• Findings and recommendations will be fed back to relevant FSA teams to inform policy making 
• The audits will ensure that the FSA is fulfilling its’ statutory function.

Strategic Outcomes

• The audits will raise the profile of the food service within LAs and help them maintain/enhance their resource allocation
• Robust assurance on the LA implementation of Official Feed and Food Control (OFFC) requirements
• Improved business compliance with food hygiene and standards contributes to improved public health and reduces the likelihood of foodborne illness, food incidents and food fraud
• Contribute towards FSA strategic risk management and compliance with UK obligations under OFFC requirements & the Food Standards Act 1999

Annex B: Allergen controls audit action plan

Action Plan for Wrexham County Borough Council 
Audit Date: 4th - 6th November 2025
 

TO ADDRESS (RECOMMENDATION INCLUDING STANDARD PARAGRAPH)	BY (DATE)	PLANNED IMPROVEMENTS	ACTION TAKEN TO DATE
4.1.16  The authority should: (i) Ensure the annual performance review includes all information on the previous year’s performance against the food service plan and any specified performance targets, standards and outcomes.	Next Service Plan (April 2026)	Service plan to be updated to include previous years review in all areas identified within the service plan
4.1.16 (ii) Ensure all variances in meeting the food service plan is addressed in its subsequent plan.	Next Service Plan (April 2026)	Service plan to be updated to include previous years review in all areas identified within the service plan
4.2.9 The authority should (i) Ensure it has a sufficient number of suitably qualified and experienced staff so that official controls and other official activities can be performed efficiently and effectively.	April 2026	Replace a retiring 0.8FTE Food Officer with a full time officer from April 2026. Train appropriately an existing Technical Officer within the Public Protection Service so that they may contribute additional staffing resources of 0.3FTE from April 2027.   Seek budget resources internally from year 26/27 to fund 0.5 FTE post.
4.3.17 (i) Ensure that food standards interventions/inspections are carried out at the minimum frequency specified by the FLCoP.	End of march 2026	Intention to realign with intervention frequencies of Code of Practice by end of March 2026. Considering use of use of AEAs for C rated inspections.	Interventions have been identified and allocated as a project to an officer.
4.3.17 (ii) Ensure that observations made and/or data obtained in the course of a food standards intervention/inspection includes complete information for assessments of food standards management systems, labelling, presentation and whether to take samples.	End of January 2026	New Inspection Proforma created and training on new proforma to be delivered to staff	5 out of 7 Staff trained in new proforma
4.3.17 (iii) Ensure premises are rated correctly in relation to allergen matters and that justification for any revision is recorded.	End of January 2026	Retraining of Officers and increase of internal monitoring	5 out of 7 staff retrained
4.3.17 (iv) Ensure that the establishment database & any information management system is capable of retrieving all food establishment information and providing the information requested by the FSA. Ensure that intervention report letters contain all of the required information.	End of January 2026	Retraining of Officers and increase of internal monitoring	5 out of 7 staff retrained
4.4.6 (i) Ensure that appropriate action is taken in relation to non-compliance following sampling.	End of January 2026	Retraining of Officers and increase of internal monitoring	5 out of 7 staff retrained
4.5.5 (i) Ensure that food complaints or service requests are thoroughly investigated and appropriate action taken in relation to non-compliance.	End of January 2026	Officers retrained on food complaint procedure, advised to recorded professional judgement on complaint. Increase of internal monitoring
4.6.7 (i) Review and amend its enforcement policy to include criteria for the taking of informal action, the service of various statutory notices and other formal actions as required by the FLCoP.	End of March 2026	Enforcement Policy to be reviewed	Policy been reviewed and in process of obtaining Council approval
4.6.7 (ii) Review and amend its enforcement procedures to include local arrangements for drafting and maintaining proof of service for statutory notices along with the process of compiling and approving files for decisions on prosecution / simple cautions.	End of December 2025	Enforcement procedures to be reviewed and amended appropriately	Procedures have been updated
4.6.7 (iii) Ensure appropriate enforcement action is undertaken to ensure non-compliance identified during interventions is remedied. This should include the provision of information to FSA Incidents Team and other local authorities.	End of January 2026	Re-training of staff and a guide to be produced to assist officers	Guide produced re-training planned for early 2026
4.7.9 (i) Revise its documented internal monitoring procedures to ensure all relevant activities are subject to proportionate monitoring. This should specify an increased sample size / frequency of internal monitoring activity and a wider range of bulk database checks.  The amount and extent of internal monitoring taking place in practice should, similarly, be expanded to include an increased sample size / frequency of internal monitoring activity and a wider range of database checks.	End of January  2026	To review Internal Monitoring Procedure	None